working together to improve patient safety…innovations in my … · 2018-03-22 · with...
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Working Together to Improve Patient Safety…...Innovations in Fall Prevention
Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANNurse Consultant
Former Associate Director, VISN 8 Patient Safety CenterFormer Associate Chief for Nursing Service/Research
E-Mail: [email protected]
My Hope:n Change practice beyond usual care of
prevention and protectionn Generate Confidence in Changen Embrace Innovation n Inspire Successful Implementation
My Goalsn Challenge and Inspire you to add
precision through the use of AvaSys to your patient safety practices and redesign fall prevention clinical practices to protect patients from Injurious Falls as your organization’s Primary Outcome
Challenges
What are the challenges for inpatient facilities
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Patient Harm… remember the news?n IOM: To Err Is Human, Shaping the
Future of Healthcare (1999)n 48,000 perhaps as much as 95,000 die
each year in hospitals as a result of medical errors that could be prevent
Dr. J. James 2013 Updaten Provided updated estimate of patient harmn Examined studies 2008-2011n MDs had to concur on final adverse events
then classify the severity of harmn True number of premature deaths associated
with preventable harm estimated at more than 400,000/year
n Serious harm 10-20 fold more common than lethal harm
Patient Safety America, Houston, TX. A new, evidence-based estimate of patient harms associated with Hospital Care (2013). Journal Pt Safety, 9: 122-128.
Conclusionsn Epidemic of patient harm in hospitals must be
taken serious if to be curtailedn Fully engage patient and their advocates during
hospital caren Systematically seek the patient voice in identifying
harms n Transparent accountability for harmn Intentional correction of root causes of harm
Do you agree?n The action and progress in patient
safety is frustratingly slown These estimates cause outcry for
overdue changes and vigilancen We can do better
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Falls: The Big Picturen > 1million patient falls occur annuallyn 20% of all hospital inpatients in US fall @ least
1X during hospital stayn 30% result in injuryn 10% result in serious injury—fracture, head
trauman Over 95% of hip fractures are caused by fallsn Patients >75 years now comprise 22% of
hospital admissions
Falls at BedsideAging Hospital Population: 2010n 45% of the inpatient hospital
population in the US was 65 years of age and older
n among whom 19% were ages 75-84, and
n 9% 85 and older Levant, S., Chari, K., & DeFrances, C.J. (2015). Hospitalizations for patients age 85 and over in the United States, 2000-2010. NCHS Data Brief. No. 182. Available at: hppt://www.cdc.gov/nchs/data/databriefs/db182.htm.
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Final 2014 AHRQ National Scorecard Data on HACs
2.4% decrease in falls but more work to do
2,750 lives saved but we can save more
Where are we? Change in HACs, 2011-2015 (Total = 3,097,400)
National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Netwo Healthcare Cost and Utilization Project.
Targeted InterventionsPrevention + Protection + Surveillance
Preventionn The act of preventing, forestalling, or hinderingPlus Protectionn Shield from exposure, injury or destruction (death)n Mitigate or make less severe the exposure, injury or
destructionPlus Surveillancen Detection
5 Essentials to Protect from FRI
You can protect patients from injurious falls
Programmatic Shift
Change in assessment structures: add risk for
FRI and Hx of FRI
Change in interventions
: Environmenta
l Redesign
Assess to protective
interventionsOrganization
al Support
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2007 JCAHO Standard: Fall Prevention Program
n Establish a Fall Prevention Programn Evaluationn Interventionsn Educate Staffn Educate Patients and Familiesn Program Evaluationn Sept 28, 2015: TJC Sentinel Alert:
Preventing Falls and Fall Injuries
Suggestions from TJCn Lead efforts to raise awareness of the need to prevent
falls resulting in injuryn Establish an interdisciplinary falls injury prevention
team or evaluate the membership of the team in place n Use a standardized, validated tool to identify risk
factors for falls n Develop an individualized plan of care based on
identified fall and injury risks, and implement interventions specific to a patient, population or setting
Suggestions con’tn Standardize and apply practices and interventions
demonstrated to be effective, including: n A standardized hand-off communication process n One-to-one education of each patient at the bedside
n Conduct post-fall management, which includes: a post-fall huddle; a system of honest, transparent reporting; trending and analysis of falls which can inform improvement efforts; and reassess the patientn Conduct a post-fall huddle n Report, aggregate and analyze the contributing factors
on an ongoing basis to inform improvement efforts.
Shiftingn From Reducing Falls to Protecting from
Fall Related Injuryn Integrate Injury Risk /History on
Admissionn Implement Universal Injury Reduction
Strategiesn Implement Population-Specific Fall
Injury Reduction Interventions
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Hospital Falls: D. Oliver, et al. Falls and fall-related injuries in hospitals. (2010, Nov). Clinics in Geriatric Medicine.
n 30% to 51% of falls result with some injuryn 80% - 90% are unwitnessedn 50%-70% occur from bed, bedside chair
(suboptimal height) or transferring between the two; whereas in mental health units, falls occur while walking
n Risk Factors: Recent fall, muscle weakness, behavioral disturbance, agitation, confusion, urinary incontinence and frequency; prescription of “culprit drugs”; postural hypotension or syncope
Most effective, fall prevention interventions should be targeted at both point of care and strategic levels
n Best Practice Approach in Hospitals:n Implementation of safer environment of care for
the whole patient cohort (flooring, lighting, observation, threats to mobilizing, signposting, personal aids and possessions, furniture, footwear)
n Identification of specific modifiable fall risk factorsn Implementation of interventions targeting those
risk factors so as to prevent fallsn Interventions to reduce risk of injury to those
people who do fall (Oliver, et al., 2010, p. 685)
Interventions: Fall and Injury Prevention Programn Fall risk Management Programn Falls Coordinatorn Goal Settingn Evidence-based risk assessment tool and
detailed management strategiesn Tailored Care Plan based on assessment and
PT, OT, Medical and Specialist Referralsn Redesigned use of signagen Fall and Injury Risk Reduction
Limits to Sciencen Failure to Differentiate Type of Fall
n Accidentaln Anticipated Physiologicaln Unanticipated Physiological (Morse 1997)
n Failure to Link Assessment with Intervention
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What can we change to move faster?n Current situation:
n Over-reliance on Fall Risk Screening
n Insufficient Risk Assessment
n Lack of Differential Diagnosis: Pathophysiology Underlying Fall Risk Factors
n Undetermined Range of Severity – Don’t know vulnerability – Level of Risk
n Understand that just about everyone is at risk for a fall
n Let’s STEP UP our game!n Set and be accountable
for achieving bold goals. In our care:n No one dies from a fall n No one breaks a hip
n Mitigate or eliminate patients' modifiable fall risk factors
Current Interventions are Not WorkingPreventionn Patients are still fallingn Universal fall precautions are insufficientPlus Protectionn Patients are still getting injured n Staff are reluctant to adopt fall injury interventionsPlus Surveillancen Most Falls are still Unwitnessedn Over-reliance on bed alarms
Protecting Patients from Harm –Our Moral Imperative
PROTECTION:Protect from Injury
Biomechanics of Fall-Related Injuries
Understanding the “rate of splat” and its
impact on injury
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Falls from High Bed: Foot First Falls from Low Bed: Foot First
Floor Matbedside fall cushion
Floor Cushion
Soft Fall bedside matTri-fold bedside mat
Roll-on bedside mat
Bedside Mats – Fall Cushions
Feet First Fall from Bed§ No Floor Mat fall over top of bedrails: ~40%
chance of severe head injury§ No Floor Mat, low bed (No Bedrails): ~25%
chance of severe head injury§ Low bed with a Floor Mat: ~ 1% chance of
severe head injury
Summary of Results
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Technology Resource Guide: Bedside Floor Mats
§ Bedside floor mats protect patients from injuries associated with bed-related falls.
§ Targeted for VA providers, this web-based guidebook will include: searchable inventory, evaluation of selected features, and cost.
Hip Protectors
Hip Protectors – Examples Hip Protector Toolkit
§ This web-based toolkit will include: § prescribing guidelines § standardized CPRS orders § selection of brands and models § sizing guidelines§ protocol for replacement § policy template § laundering procedure § stocking procedure § monitoring tools § patient education materials§ provider education materials
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Moderate to Serious Injury: A, B, C, Sn Those that limit function,
independence, survivaln Agen Bones (fractures)n Bleeds / AntiCoagulation (hemorrhagic
injury)n Surgery (post operative)
Universal Injury Preventionn Educates patients / families / staff
n Remember 60% of falls happen at home, 30% in the community, and 10% as inpts.
n Take opportunity to teachn Remove sources of potential laceration
n Sharp edges (furniture)n Reduce potential trauma impact
n Use protective barriers (hip protectors, floor mats)n Use multifactorial approach: COMBINE Interventionsn Hourly Patient Rounds (comfort, safety, pain)n Examine Environment (safe exit side)
Age: > 85 years oldn Education: Teach Back Strategiesn Assistive Devices within reachn Hip Protectorsn Floor Matsn Height Adjustable Beds (low when
resting only, raise up bed for transfer)n Safe Exit Side n Medication Review
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Bonesn Hip Protectorsn Height Adjustable Beds (low when
resting only, raise up bed for transfer)n Floor Matsn Evaluation of Osteoporosis
Bleeds/AntiCoagulationn Evaluate Use of Anticoagulation: Risk
for DVT/Embolic Stroke or Fall-related Hemorrhage
n Patient Educationn TBI and Anticoagulation: Helmetsn Wheelchair Users: Anti-tippers
Surgical Patientsn Pre-op Education:
n Call, Don’t Falln Call Lights
n Post-op Educationn Pain Medication:
n Offer elimination prior to pain medicationn Increase Frequency of Rounds
It is time to Think out of the Box
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Use of Video Surveillance –Patient Engagementn Fail Teach Backn Able to get out of bedn Cognitively Impairedn Impulsiven Assisted Toiletingn Over estimate abilitiesn (NOT At Risk for Falls)
Where Surveillance is Neededn Patient Roomn Hallwaysn Dining Rooms
Shifting: All National Guidelinesn From Reducing Falls to Protecting from
Fall Related Injury.n Integrate Injury Risk / History on
Admission.n Implement Universal Injury Reduction
Strategies.n Implement Population-Specific Fall
Injury Reduction Interventions.Add Patient Engaged Surveillance
Rehabilitation Nursing Articlen Sequential Cohort Studyn 15 video monitoring units on high risk units -
115 bed inpatient rehab hospital – 12 monthsn Outcome reduced average hospital rate of falls
6.34 / 1000 hospital patient days to 5.099 (t (31) = 2.034, p=.0496)
n Brain Injury Unit: 10.26 falls / 1000 hospital patient days to 6.87 falls/1000 pt days (t(18)=2.647, p=0.16)
Cournan, M., Fusco-Gessik, B., Wright, L. (2016). Improving patient safety through video monitoring. Rehabilitation Nursing, 0: 1-6
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Other Findingsn 95 interventions every 24 hours n 28 falls by patients on video monitoring
over total of 3,641 patient-days n 37 falls for non-monitored patients over
5,788 patient daysn Note: did not limit falls to those under
surveillance Votruba, L., et al, “Video Monitoring to Reduce Falls and Patient Companion Costs for Adult Inpatients,” Nursing Economics, July/August 2016
© 2016 AvaSure Holdings, Inc. All rights reserved.
Nursing Economic$ ArticleProspective Descriptive Study
During the intervention phase, video monitoring was implemented on three nursing units. Ten to twelve patient were monitored each day based on nursing assessment of high fall risk combined with some level of confusion. Fall Reduction Results: Statistically significant decrease in falls by 35% (p<0.0001, 95% CI)
Fall Reduction ResultsStatistically significant decrease in falls by 35% (p<0.0001, 9% CI)
Baseline(9 months)
Intervention (9 months)
Falls 85 53Total Pt Discharges 5,109 5,041Fall/Pt discharge 1.7% 1.1%
Process Outcomesn Telesitters redirected patients 5,413 times (avg 10xs /
shift)n 828 patients monitored – 13 had a fall (avg monitor 2.5
days)n 4,213 patients not-monitored – 40 fallsn Annualized avoidance of 37 falls / year for the 3
intervention unitsn Avoided $52,000-$87,000 fall costn Combined with reduced sitter use, saved $77,200-
$112,000 / year
Patient Outcomesn Reduced Falls (True Positive)n Reduced Falls with Injuryn Reduced Sitter Usagen Elimination of Alarms
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Additional Outcomes n Shift in Nursing Beliefs: Nursing culture can
shift and trust and use new technology to improve patient safety and outcomes
n Real-time Surveillance decreases noise, stimulation and alarms, and increases rest and sleep
n Real-time Surveillance provides better focus for nursing practices as the observers are more fully present
n Falls can be prevented beyond the bedroom, such as to the day room, the hallway
n Motivates staff towards resultsn Utilization data at your fingertips to help with change
managementn Informs clinical decision-makingn Optimizes operational management of video
monitoring programn Event investigationsn Staff responsiveness (response times, alarm fatigue
data)n Begins to provide insight into what causes falls and
other adverse events
The Benefits of Video Monitoring Data:
© 2015 AvaSure Holdings, Inc. All rights reserved.
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